cms_GA: 8305
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8305 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2012-02-23 | 323 | D | 0 | 1 | T14011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to consistently implement planned interventions for one resident (#75) with a history of falls and skin tears and to secure a disposable razor from one resident (#28) in a total sample of 33 residents. Findings include: 1. Resident #75 had a [DIAGNOSES REDACTED]. On the resident's 12/1/12 quarterly Minimum data set (MDS) assessment, he/she was coded as needing extensive assistance with transfers and dressing. The resident had history of falls. Licensed nursing staff documented that the resident had fallen twice in February 2012 January 2012 and December 2011, once in November 2011 and eight times in October 2011. Nursing notes documented that the resident had fallen on 2/01/12 and 2/08/12 when he/she transferred independently out of bed. The care plan initiated on 6/13/2011 had an intervention for staff to keep slip resistant footwear on the resident at all times when he/she was out of the bed. However, it was observed on 2/22/12 at 12:50 p.m. and 4:25 p.m. and on 2/23/12 at 11:30 a.m. that the resident was out of bed but was not wearing slip resistant footwear. During an interview on 2/23/12 at 11:30 a.m., the Director of Nursing stated that the use of non-skid socks on the resident when he/she was up should be changed to him/her needing to wear them at all times because of his/her attempts to transfer independently from the bed. There was a handwritten intervention on the care plan for staff to apply a bed/chair alarm on the resident. However, during an observation on 2/22/12 at 12:50 p.m., the personal alarm had not been attached to the resident. A handwritten intervention (dated 8/24/11) on the care plan noted that the resident's wheelchair was moved to his/her bedside. There was a 10/11/11 note that the resident's wheelchair brake had been repaired by maintenance. During observations on 2/22/12 at 4:25 p.m. and on 2/23/12 at 8:15 a.m., 10:45 a.m. and 11:30 a.m., the wheelchair was positioned next to the resident's bed but, staff had not locked the brake on the left side of the chair. Observations during those times revealed that the brake locks were functional on the wheelchair. The resident's care plan since 6/13/11 addressed his/her potential for having skin tears and noted his/her history of having had multiple skin tears on his/her upper extremities. There was an intervention since 10/17/11 for staff to monitor the resident and apply sleeves on both of his/her arms. There were handwritten entries on the care plan that the resident had sustained skin tears on his/her left upper extremity on 7/16/11, 8/05/11, 8/22/11, 9/23/11, 10/04/11, 10/06/11, 10/20/11, 11/14/11, 12/07/11, 01/13/12, 01/30/12, and 02/01/12. Staff documented that he/she had sustained skin tears on his/her right upper extremity on 8/15/11, 8/30/11, 9/23/11, 10/08/11, 01/16/12, and 02/08/12. However since the intervention was added on 10/17/11, there was not any evidence of whether or not the resident had been wearing sleeves when any of those the skin tears occurred. The resident was observed on 2/20/12 at 1:55 p.m., and on 2/23/12 at 8:15 a.m. wearing short sleeve shirts. He/She had multiple bruises on both of his/her lower arms and a skin tear on his/her left hand. During an interview on 2/23/12 at 11:30 a.m., the Director of Nursing stated that she was not aware of any preventative measures that had been put into place to protect the resident's arms. The care plan since 6/13/11 addressed the resident's cognitive loss and dementia with short term memory impairment. There was an intervention for staff to keep his/her call light within reach and to respond to it promptly. Staff documented on the care plan on 10/20/11 that the resident had been reminded to call for assistance as needed. However, that intervention was not appropriate because, it required a response of which the resident was not capable based on the facility's assessment of his/her cognitive status and short term memory problems. 2. Resident #28 had been coded on his/her 1/26/12 MDS assessment as cognitively impaired and needing assistance for activities of daily living. However, during an observation on 02/22/12 at 8:49 a.m., the resident sat alone in a bedside chair in his/her room with a disposable razor on the floor behind his/her foot. That observation was confirmed by the A hall charge nurse. Review of a facility's inservice records dated 04/15/11 included a reminder that razors were supposed to be removed from rooms. The attendance record was signed by 29 certified nursing assistants (CNA). | 2016-03-01 |